Page last updated: Sep 27, 2022
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If you disagree with the outcome of a coverage determination, you, your appointed representative, or your prescribing physician may file an appeal called a plan “redetermination”. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for delay. Please refer to your Evidence of Coverage located on the Plan Documents page that discusses the five (5) levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your initial coverage request. You also have the right to give us new information supporting your appeal request. We also check to see if we were being fair and following all the rules when we said no to your initial request. We may contact you or your doctor or other prescriber to get more information.
How to request a Part D appeal
You or your appointed representative (your doctor, attorney, advocate, relative, friend or other person authorized to act on your behalf) can submit an online Part D appeal request fax, mail or call in a request for a redetermination.
- ONLINE: To submit your Part D appeal request online, please click here.
- FAX: To fax your Part D appeal request, complete the correct coverage determination request form and fax to Elixir at 1-877-503-7231. These forms can be found on the Formulary Restrictions page. If you are not sure which form to use, you can complete a general request form called the Request Medicare Prescription Drug Coverage Determination.
- MAIL: Please complete the correct coverage determination request form which can be found on the Formulary Restrictions page. If you are not sure which form to use, you can complete a general request form called the Request Medicare Prescription Drug Coverage Determination. Once completed, mail your Part D appeal to:
Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087
- PHONE: To file a Part D appeal request by phone, call 1-855-791-5302 (TTY 711). Hours: 24 hours a day, 7 days a week.
PLEASE NOTE: Those not authorized, under state law, to act for you must first sign an Appointment of Representative Form (English) (English- Large Print) (Español) (Español – Letra Grande) and either fax to Elixir at 1-877-503-7231 or mail it to the below address:
Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087
How long it takes for a Part D appeal decision
A standard appeal decision will be made within 7 calendar days. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 30 calendar days.
If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing doctor may request an expedited appeal for a decision within 72 hours. This process does not apply to denied claims for payment.
Status requests
For questions regarding the process or status of a Part D appeal request, you, your physician or your appointed representative should call Elixir, Care N’ Care’s pharmacy benefit manager, at this toll-free number: 1-855-791-5302 (TTY 711). Hours: 24 hours a day, 7 days a week.
Part D Grievances
A grievance is any dispute other than one that involves a coverage determination that expresses dissatisfaction with the operations, activities or behavior of Care N’ Care or one of our providers. For example, a grievance can involve the behavior of a network pharmacist, the ability to get the information you need from a customer service representative, or the condition of a network pharmacy.
You must file a grievance within 60 days from the date of the event that led to the complaint. Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast coverage determination or redetermination and you haven’t purchased or received the drug. We will address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.
How to file a Part D Grievance
- PHONE/VERBAL: If you would like to file a verbal grievance by phone, call your Care N’ Care Customer Experience Team at 1-877-374-7993 (TTY 711) October 1 – March 31, seven (7) days a week/8 a.m. – 8 p.m. (CST), or April 1 – September 30, Monday through Friday, 8 a.m. – 8 p.m. (CST).
- Fax: 1-817-438-8483
- Mail:
Care N’ Care
Attn: Part D Appeals and Grievances
1603 Lyndon B. Johnson Freeway, Suite 300
Farmers Branch, TX 75234
For more information, you can call the Care N’ Care Customer Experience Team at the phone number listed above.
Status requests
For questions regarding the process or status of a Part D grievance call your Care N’ Care Customer Experience Team at 1-877-374-7993 (TTY 711) from October 1 – March 31, 8 am – 8 pm, (CST) seven days a week or April 1 – September 30, 8 am – 8 pm (CST), Monday through Friday.
Care N’ Care tracks and maintains records about the receipt and handling of grievances, appeals and exceptions. We will also disclose grievances, appeals and exceptions data to you upon request. To obtain this data, please call the Care N’ Care Customer Experience Team at the phone number listed above.
Complaints and disenrollment
If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrollment on the Your Rights page.
